Integrating Medical Acupuncture and Intraoral Dry Needling Protocol for Radiation-Induced Xerostomia

ABSTRACT

Clinical trials have shown that acupuncture may be effective in treating xerostomia.2 Acupuncture reduces symptoms related to xerostomia in patients who are refractory to current management such as pilocarpine.3 A 60-year old female patient presented with xerostomia after receiving radiation for adenoid cystic carcinoma. Patient reported attempting various treatment modalities to improve RIX that included but not limited to Pilocarpine prescription and over the counter saliva substitutes. After 3 months, patient decided to seek care at UCLA School of Dental Medicine’s Orofacial Pain Clinic for dental acupuncture treatment. We opted to utilize Dr Niemtzow’s protocol for this case study. Dr Richard Niemtzow, a colonel in the US Air Force, created an acupuncture protocol that is point precise to treat radiotherapy-induced xerostomia (RIX) for cancer patients.6 Per Dr Niemtzow’s medical acupuncture protocol, three auricular and four digital points were bilaterally placed for 45 minutes. Patient subsequently received intraoral dry needling protocol on two tongue and two palatal acupuncture points for two minutes. Treatment was repeated the next day. By including dental acupuncture after Dr Niemtzow’s protocol, saliva production increased by an average of two times more compared to Dr Niemtzow’s stand alone treatment. The intraoral acupuncture protocol may have additionally stimulated the parotid, submandibular, sublingual, and minor palatal salivary glands, resulting in an increase of salivary production. Studies have shown at least two neuropeptides, vasoactive intestinal peptide and calcitonin gene-related peptide, to be present in salivary glands that can stimulate salivary secretion.7 The intraoral dry needling protocol is an invaluable addition to provide relief from radiation-induced xerostomia. Further investigation with a larger patient population should be considered to standardize dental acupuncture.

KEYWORDS:

• Case report
• acupuncture
• dental acupuncture
• medical acupuncture
• xerostomia
• recalcitrant xerostomia
• radiation induced xerostomia
• dysgeusia
• dysphagia
• odynophagia

Introduction

Dental complications, dysgeusia, dysphagia, odynophagia, and difficulty sleeping and speaking affect quality of life and are often associated with radiation-induced xerostomia in head and neck cancer patients.¹ Current methods to manage xerostomia include stringent oral hygiene using fluoride agents and antimicrobials, saliva substitutes, and sialogogic agents. However, side effects such as headache, dizziness and sweating often occur with these therapeutic modalities.

Clinical trials have shown that acupuncture may be effective in treating xerostomia.² Acupuncture reduces symptoms related to xerostomia in patients who are refractory to current management such as pilocarpine.³ Systematic reviews demonstrated that acupuncture is helpful to cancer survivors with symptoms such as cancer-related pain, fatigue, insomnia, nausea and vomiting, bone marrow suppression, menopausal symptoms, arthralgia, and dysphagia, and also shows potential for lymphedema, gastrointestinal function, and xerostomia.⁴ There were considerable heterogeneities in the current acupuncture treatment protocols for radiation-induced xerostomia. Five ancient Chinese classic acupuncture protocols targeted approximately 48 acupuncture points for xerostomia in patients of various constitutions.⁵

To eliminate such variability, we opted to utilize Dr Niemtzow’s protocol for this case study. Dr Richard Niemtzow, a colonel in the US Air Force, created an acupuncture protocol that is point precise to treat radiotherapy-induced xerostomia (RIX) for cancer patients.⁶ According to Dr Niemtzow, “A standardized acupuncture protocol does not exist for dry mouth symptoms post radiation. However, I have developed a combination of auriculotherapy (ear acupuncture) and body acupuncture that have been very effective.

Methods

A 60-year-old female patient presented with xerostomia after receiving radiation for adenoid cystic carcinoma. Patient’s chief complaints were continuous dryness and bitter taste post radiotherapy. Patient’s radiation-induced xerostomia was affecting her ability to maintain a healthy and well-rounded diet as she had to soak every meal in liquid to assist with deglutition. For the case report, the Visual Analogue Scale (VAS) was utilized to measure the intensity of symptoms before and after treatment. 0 indicated no dryness and discomfort while 10 denoted extreme dryness and discomfort. Within the intake forms, patient reported a VAS score of 7 out of 10.

During the initial patient examination, we noted foamy saliva, protrusion of purple veins underneath her tongue, purple tongue color presentation, severe scalloping on the lateral border of the tongue, and moderate cheek ridging (Figure 1). According to Traditional Chinese Medicine’s (TCM) principles, patient had yin and spleen deficiency with liver qi-blood stagnation.

Figure 1. Tongue presentation during initial patient exam.

Patient reported attempting various treatment modalities to improve RIX with her oncologist that included but not limited to Pilocarpine prescription and over the counter saliva substitutes. After 3 months, patient decided to seek care at UCLA School of Dental Medicine’s Orofacial Pain Clinic for dental acupuncture treatment.

Patient provided consent to participate in our case study to treat her RIX with both Dr Niemtzow’s Dry Mouth Protocol and UCLA School of Dentistry Orofacial Pain Clinic’s Intraoral Dry Needling Protocol (Tables 1 and 2). During every treatment session, we treated the patient with Dr Niemtzow’s medical acupuncture protocol as well UCLA’s dental acupuncture protocol. Total treatment sessions for our patient consisted of two appointments 24 h apart.

Table 1. Dr Niemtzow’s dry mouth protocol.

Place needle in the right ear: Salivary Gland- 2 Place needle in the right-index finger: Large Intestine- 1 Place needle in the left-index finger: Large Intestine- 1 Place needle in the left ear: Salivary Gland- 2 Place needle in the left ear: Shen Men Place needle in the left ear: Point Zero Place needle in the right ear: Shen Men Place needle in the right ear: Point Zero Wait 10 min. Then, evaluate salivary volume and viscosity by expectorating into a 14 ml saliva collection tube and measuring saliva production after 5 min. Place needles in the bilateral index fingers, specifically distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints Evaluate salivary volume and viscosity by expectorating into a 14 ml saliva collection tube and measuring saliva production after 5 min. Repeat treatment steps 1–12 in 24 h. Thereafter, patient must dissolve a sugarless mint every 2 h for the next 2 weeks except at bedtime.

Table 2. UCLA school of dentistry orofacial pain clinic’s intraoral acupuncture protocol.

Pack 2x2 cotton gauze bilaterally between mandibular teeth and cheeks. Ask the patient to protect his/her tongue by pushing the tongue towards the maxillary anterior dentition with two tongue blades and hold for 2 min. Place two acupuncture needles under the tongue-targeting the submandibular glands or JinJin-YuYue points with 1.5–2 in 36 gauge needles. Pack 2x2 cotton gauze to protect the airway space from loose acupuncture needles. Place two acupuncture needles on minor palatal salivary glands with 1.5–2 in 36 gauge needles. Remove all needles prior to removing cotton gauze.

Per Dr Niemtzow’s medical acupuncture protocol, three auricular and four digital points were bilaterally placed for 45 min (Figures 2 and 3). Patient subsequently received UCLA’s intraoral dry needling protocol, targeting two tongue and two palatal acupuncture points, for 2 min (Figure 4). Treatment was repeated in the same manner the next day.

Figure 2. Acupuncture needle placement on bilateral index fingers.

Figure 3. Acupuncture needle placement on bilateral ears (left and middle image: left ear/right image: right ear).

Figure 4. Intraoral acupuncture needle placement.

To measure the patient’s baseline saliva producing capability, patient was provided a sugar-free lozenge to dissolve intraorally for 2 min. Thereafter, patient was given 5 min to collect saliva in a 14 ml saliva collection tube. After each treatment protocol, a lozenge was administered for the patient to dissolve for 2 min before collecting saliva for 5 min.

Results

During the patient’s first treatment session, pretreatment saliva production totaled 2.25 ml. After 45 min of Dr Niemtzow’s auricular and digital point therapy, the patient produced 2.75 ml of saliva. After 2 min of intraoral dry needling protocol, the patient generated 3.25 ml of saliva. Including the intraoral dry needling protocol for 2 min improved saliva production by 2.18 times more compared to Dr Niemtzow’s standalone treatment.

Patient checked in 24 h later for the second treatment appointment. Patient filled out a follow-up questionnaire where she reported improvement in saliva production and dry food consumption without liquids. However, patient reported persistent nighttime awakenings to drink water as well as continuous bitterness and dull taste sensation. Prior to the second treatment session, retreatment saliva production totaled 2.5 ml. After 45 min of Dr Niemtzow’s auricular and digital point therapy, the patient produced 2.75 ml of saliva. After 2 min of intraoral dry needling protocol, the patient generated 2.4 ml of saliva. Including the intraoral dry needling protocol for 2 min improved saliva production by 1.87 times more compared to Dr Niemtzow’s standalone treatment.

Table

	Pre txt volume (A)	Dr. Niemtzow’s protocol (B)	UCLA’s protocol (C)	Total post txt volume (B+C)	B/A (%)	B+C/A (%)	Efficacy difference (%)
12/08/2023	2.25 ml	2.75 ml	3.25 ml	6.0 ml	122.22%	266.67%	2.18x
12/09/2023	2.5 ml	2.75 ml	2.4 ml	5.15 ml	110%	206%	1.87x

The volume of saliva obtained after implementing UCLA’s Intraoral Needling Protocol was substantially greater than that obtained through Dr Niemtzow’s protocol. The intraoral acupuncture protocol may have additionally stimulated the parotid, submandibular, sublingual, and minor palatal salivary glands, resulting in an increase of salivary production. Studies have shown at least two neuropeptides, vasoactive intestinal peptide and calcitonin gene-related peptide, to be present in salivary glands that can stimulate salivary secretion.⁷

According to Dr Niemtzow’s 2000 study at UC San Diego, the positive treatment result persists up to 12 weeks post-therapy.⁸ During our patient’s telehealth appointment 4 months after treatment at UCLA School of Dental Medicine, patient reported that she does not have to wake up multiple times a night to drink water. Patient continues to enjoy meals without soaking them in liquid, the bitter taste sensation has disappeared, and the patient has regained taste sensation.

As with any research, we experienced limitations in our case study. First, the patient reported one round of radiation to the head and neck the morning of our second treatment session. This may be the cause of the second treatment session yielding less success (1.87× vs 2.18×) than the first treatment session.

Second, the patient received TCM acupuncture treatments after our two treatment sessions. This unaccounted variable may have influenced her symptom improvement during the four-month follow-up visit. We do not have longitudinal studies but a randomized clinical trial showed patients who received acupuncture had significantly lower xerostomia scores 12 months after the end of radiation therapy than that of the standard care control group.¹ Last but not least, simply placing objects in the mouth can potentially stimulate saliva. However, our data clearly established substantial improvement between baseline levels, Dr Niemtzow’s protocol, and our integrative intraoral protocol.

Conclusion

This case is not only unique but also extremely rare to find in published literature as we uniquely combined Dr Niemtzow’s medical acupuncture and UCLA School of Dentistry Orofacial Pain Clinic’s Intraoral Dry Needling Protocol to treat radiation-induced xerostomia. By including dental acupuncture 2 min after Dr Niemtzow’s protocol, saliva production increased by an average of two times more compared to Dr Niemtzow’s stand alone treatment. The intraoral dry needling protocol is an invaluable addition to provide relief from RIX. It is important to note that this treatment protocol is not a two session “cure” but success has been observed with multiple treatment sessions. Further investigation with a larger patient population should be considered to standardize dental acupuncture.

Acknowledgment

Dental acupuncture has been taught and practiced at UCLA School of Dental Medicine since the early 1980s for various orofacial pain conditions. UCLA Health Center for East-West Medicine has also educated their residents on medical acupuncture for the past 30 years. At the UCLA Health Center for East-West Medicine, Dr Richard Niemtzow’s lecture in 2021 taught us his updated protocols on how to treat recalcitrant RIX.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

S. J. Lee

S. J. Lee (DMD) is a board certified orofacial pain and dental sleep medicine specialist. After earning her doctorate from Tufts University School of Dental Medicine, Dr. Lee went on to complete her residency at UCLA School of Dental Medicine. Her areas of interest include TMJ and jaw pain/dysfunction, nerve pain in the face, headaches, and obstructive sleep apnea. Dr. Lee provides comprehensive treatment approaches uniquely tailored to each patient. To ensure patients have a full understanding of their condition, Dr. Lee is committed to open communication and patient education.

C. P. Diep

C. P. Diep (DDS, LAc) is a licensed dentist who has successfully treated patients for more than 32 years. She is a graduate of the UCLA School of Dentistry in 1989 where she earned a Doctorate in Dental Surgery. Dr. Diep is a Diplomate of American Board of Orofacial Pain (ABOP) and Diplomate of Oriental Medicine (NCCAOM). She is also a California Licensed Acupuncturist. Dr. Diep is a teaching faculty of UCLA center for East-West Medicine and a clinical educator at the UCLA School of Dentistry.

S. Arman

S. Arman (DMD, MPH) is the director of the orofacial pain program and continuing dental education program at the UCLA School of Dentistry. He joined the faculty as a lecturer in 2012 and also had a practice limited to Orofacial Pain. He is involved with the American Academy of Orofacial Pain and the American Board of Orofacial Pain. His interest is to promote Orofacial Pain education to healthcare providers and students as well as the integration of Orofacial Pain education into dental education curricula.

D. V. Messadi

D. V. Messadi (DDS, MMSC, DMSC) is a professor and Chair of the Section of Oral Medicine, Oral Pathology, and Orofacial Pain at the UCLA School of Dentistry. She previously served as the Associate Dean for Academic Affairs.

F. S. Younai

F. S. Younai (DDS) is a Professor of Clinical Dentistry in the Section of Oral Medicine and Orofacial Pain in the Division of Oral Biology and Medicine. In 1997 she joined the faculty of UCLA School of Dentistry, where she currently serves as Chair of the Division of Diagnostic and Surgical Sciences. Dr. Younai obtained her dental degree from the School of Dental Medicine at State University of New York at Stony Brook in 1985. After completing her training in Hospital Dentistry at Long Island Jewish Medical Center in New York, she joined the faculty of New York University (NYU) College of Dentistry in the Division of Basic Sciences. There, she was appointed as an Assistant Professor (1990–1996) and then an Associate Professor of Basic Sciences (1996–1997) and served as the Director of Hospital Dentistry, Special Patient Care and Oral Medicine from 1990 to 1997. Dr. Younai’s teaching portfolio includes courses that focus on the interplay between systemic diseases and oral health, oral diseases and their pharmacological management, and patient assessment. She chairs and teaches in a number of courses in the predoctoral curriculum in the Oral and Systemic Diseases Track.